Recently, an elderly patient suffering from moderate-to-advanced stage dementia, with behavioural complications, was hospitalized on a psychiatric admission. The patient, who was declared incapable to consent to treatment, was initially held involuntarily under the Mental Health Act, RSO 1990, C M.7 (the “MHA”). The patient had appointed a cousin as…
Dr. Richard Shulman
Dr. Shulman is a geriatric psychiatrist at Trillium Health Partners and is an associate professor at the University of Toronto. He is medical director of the Capacity Clinic and available for independent medical-legal capacity assessments.
Nathan Spaling (my colleague from the Capacity Clinic) and I are often asked to conduct capacity assessments in the context of guardianship applications. On occasion, the application is brought by a parent seeking to be appointed as the guardian of property for a child who is about to become an…
In my last blog, I described the Court’s expectation for confirming a finding of incapacity: namely, that compelling evidence is required to override the presumption of capacity. Such evidence may include corroborative information. However, the Court has warned assessors to be alive to the presence of improper motives of informants…
In clinical geriatric psychiatry, it is an accepted standard of care to obtain corroborative information when conducting clinical evaluations.However, medical-legal tasks of capacity evaluation, such as for the evaluation of capacity to instruct counsel, testamentary capacity and possibly even capacity to appoint powers of attorney, may require strict confidentiality which prevents obtaining corroborative information from informants. As a result, obtaining corroborative information for capacity evaluation in this context is more complex than in clinical care.
It is just as important to know the limitations of a power of attorney for personal care as it is to know your responsibilities.
Current approaches that define capacity in cognitive terms disregard concerns that emotional instability may disrupt capacity or that a person may be cognitively intact yet lack the capacity to give a valid consent. An alternative evaluative approach would be to view capacity holistically, as a combination of biological, psychological, and social (biopsychosocial) factors.
There appears to be a lack of consensus in the mental health field whether persons with a mental disorder-sole underlying medical condition can be adequately evaluated for capacity to consent to MAiD.
I suggest “an appreciation of the impact MAiD will have on family members and friends” be included in fulfilling the proposed amendment of the appreciation test for consenting to MAiD. The proposed amendment would not mandate being bound by others’ opinions, but that that lack of ability to appreciate the views of one’s significant others would demonstrate a lack of ability to apply the relevant information to one’s circumstances.
In Canada, the law no longer restricts medical assistance in dying (MAiD) to people whose death is reasonably foreseeable: as of March 17, 2023, people with a mental disorder as a sole underlying medical condition (MD-SUMC) will be eligible for MAiD.
I have found it uncommon for a family member or beneficiary to exert undue influence to pressure a patient to pursue MAiD. What worries me is the vulnerability of patients to undue influence from physicians who may embrace therapeutic nihilism and bias patients unduly towards MAiD. I suggest that, for capacity to consent to MAiD, the test of “ability to appreciate” should be expanded to require an appreciation of the views and wishes of supportive family members and friends.